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Equine Recurrent Uveitis – the European Viewpoint

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Equine Recurrent Uveitis – the European Viewpoint Spiess, B M (2010). Equine recurrent uveitis - the European viewpoint. In: Matthews, A; Gilger, B; Hughes, K. Equine Ophthalmology III. Cambs, UK, 50-56. Postprint available at: http://www.zora.uzh.ch University of Zurich Posted at the Zurich Open Repository and Archive, University of Zurich. Zurich Open Repository and Archive http://www.zora.uzh.ch Originally published at: Matthews, A; Gilger, B; Hughes, K 2010. Equine Ophthalmology III. Cambs, UK, 50-56. Winterthurerstr. 190 CH-8057 Zurich http://www.zora.uzh.ch Year: 2010 Equine recurrent uveitis - the European viewpoint Spiess, B M Spiess, B M (2010). Equine recurrent uveitis - the European viewpoint. In: Matthews, A; Gilger, B; Hughes, K. Equine Ophthalmology III. Cambs, UK, 50-56. Postprint available at: http://www.zora.uzh.ch Posted at the Zurich Open Repository and Archive, University of Zurich. http://www.zora.uzh.ch Originally published at: Matthews, A; Gilger, B; Hughes, K 2010. Equine Ophthalmology III. Equine Veterinary Journal Supplement 37. Cambs, UK, 50-56. Equine recurrent uveitis – the European viewpoint Bernhard M. Spiess, Dr. med. vet. DACVO/ECVO Vetsuisse Faculty, University of Zurich, Equine Department, Section of Ophthalmology Historical perspective Equine recurrent uveitis (ERU) has been a scourge for the equine population for many centuries and was also an important economic factor when the horse population in Europe was significantly larger than today (Bayer 1900). ERU was in many areas enzootic and the disease so prevalent, that some studs had to be closed altogether. The largest equine populations of that time were found in the armies and the great losses of horses due to ERU spurred the interest in this disease (Braun 1995). All through the Middle Ages the knowledge of the so-called oculus lunaticus was very limited and treatment usually consisted of various methods of bloodletting (Bayer 1900; Jakob 1920; Braun 1995). With the formation of the first veterinary schools in Europe in the 18th century a more scientific approach to diseases in general and to ocular diseases in particular was established. The development of veterinary ophthalmology was largely driven by the need to increase the knowledge about ERU. The advent of the first ophthalmoscope by Helmholtz in 1851 and the introduction of extracts of Bella Donna were important steps in the establishment of ophthalmology as a specialty in human and veterinary medicine (Braun 1995). Prevalence The prevalence varies with geographic location and climate and has been reported to be as high as 40% in endemic areas (Rosenfeld 1905; Möller 1910; Cross 1966). In certain river valleys in France the prevalence increased from 23% to 40% after severe flooding occurred in 1881 (Möller 1910). It was also noted, that in areas with clay soil and frequent flooding the prevalence could reach 70%, while in drier areas with chalky soil the incidence was around 5% (Jakob 1920). More recent reports documented a prevalence of 8% to 10% in western Germany (Szemes 2000; Deeg, Thurau et al. 2002). Aetiology of ERU The aetiology of ERU is still not absolutely clear today (Dwyer 2005). In a 1987 editorial, Barnett concluded that equine periodic ophthalmia was “a continuing aetiological riddle”(Barnett 1987). In earlier days heredity has been hotly disputed (Bayer 1900; Möller 1910; Lorbeer 1940). And there is still evidence of a possible genetic component to ERU (Angelos, Oppenheim et al. 1988; Alexander and Keller 1990; Dwyer, Crockett et al. 1995). There appears to be a breed predilection for the Appaloosa (Dwyer, Crockett et al. 1995). Although the total population of Appaloosas in Switzerland is not known, they are definitely over-represented in our ERU cases with 11/15 (73%) of Appaloosas diagnosed with ERU compared to 154/1115 (14%) of all other breeds combined. It was also observed that horses in low-lying wetlands tended to be more commonly affected than those in higher and drier areas (Zipperlen 1877). This view was still supported half a century later (Jones 1942; Jones 1949). Viral causes have been suspected but this has never been proven (Komar 1968; Attenburrow 1983). At one point microfilariae of Onchocerca cervicalis were thought to play a role in the aetiology of ERU, although today this seems to be rather exceptional (Gmelin 1935; Attenburrow 1983; Cook and Harling 1983; van der Velden and Schuitemaker 1985). 1 One of the first to propose Leptospira as the causative agent for ERU was Heusser in 1948 (Heusser 1948). Since then there is mounting evidence, that Leptospira sp. is at least the triggering factor for ERU (Roberts, York et al. 1952; Yager, Gochenour et al. 1952; Bryans 1955; Roberts 1958; Roberts 1969; Trap 1979; Hathaway, Little et al. 1981; Davidson, Nasisse et al. 1987; Matthews, Waitkins et al. 1987; Sillerud, Bey et al. 1987; Dwyer, Crockett et al. 1995; Wollanke, Gerhards et al. 1998; Wollanke, Rohrbach et al. 2001; Wollanke 2002; Wollanke 2004; Niedermaier, Wollanke et al. 2006; Gilger, Salmon et al. 2008) and it has been shown, that vaccination with a specific vaccine was successful in preventing new cases in an endemic horse population (Rohrbach, Hendrix et al. 2002; Wollanke 2004; Rohrbach, Ward et al. 2005). There are, however, geographical differences in the prevalence of Leptospira in the equine population (Verma, Biberstein et al. 1977; Slatter and Hawkins 1982; Matthews 1987; Dwyer, Crockett et al. 1995; Wollanke, Gerhards et al. 1998). In our own case records 79% of horses with ERU test positive for Leptospira sp. by microagglutination of aqueous and/or vitreous samples (Toemoerdy 2009). Nine different serovars of Leptospira were tested, the most common being L. grippothyphosa, followed by L. Canicola and L. bratislava (Toemoerdy 2009). ERU is most likely an immune-mediated disease initiated by various causes resulting in recurrent delayed hypersensitivity reactions at variable intervals (Spiess 1997a; Spiess 1997b; Dwyer 2005) (Deeg, Hauck et al. 2008). Recent studies give compelling evidence, that ERU is an autoimmune reaction with horses expressing the MHC haplotype, ELA-A9 being more susceptible to develop the disease (Deeg, Kaspers et al. 2001; Deeg, Thurau et al. 2002; Deeg, Hauck et al. 2007; Deeg, Raith et al. 2007; Deeg 2008). Clinical signs of ERU The many clinical signs and different manifestations of ERU have been extensively described elsewhere (Cook and Harling 1983; Spiess 1997; Dixon and Coppack 2002; Dwyer 2005) (Fig. 1). In our case load ERU is the most common form of uveitis seen in horses. The clinical presentation of ERU is variable. The vast majority of horses presented with clinical signs of anterior uveitis, which are easily recognisable by owners and referring veterinarians. Some of them may also have Panuveitis, although examination of the posterior segment is initially precluded by the intense miosis. A small number of patients exhibit a less obvious form of ERU, usually intermediate uveitis (pars planitis) with marked inflammatory changes of the posterior segment (vitreous). Since these horses exhibit less obvious clinical signs, they are usually presented because of visual deficits at a late stage of the disease. There appears to be no correlation between the form of uveitis and the Leptospira status of an individual patient (Toemoerdy 2009). The association between peripapillary choroidal degeneration (butterfly lesions) and ERU is equally unclear (Matthews, Crispin et al. 1990). In ponies experimentally infected with Leptospira sp. peripapillary chorioretinitis developed along with anterior uveitis (Williams, Morter et al. 1971). Diagnosis The diagnosis of ERU is based on the clinical signs of uveitis and a documented history of recurrent episodes of inflammation. In central Europe it is prudent to consider any equine uveitis to be ERU until proven otherwise. There are of course, other forms of uveitis, especially those associated with trauma. Blunt or sharp trauma to the eye is usually accompanied by some degree of uveitis (Habin 1994; Moore, Halenda et al. 1998; Grahn and Cullen 2000). Iridocyclitis and chorioretinitis have been seen in foals with septicaemia (Latimer and Wyman 1985). We have seen bilateral anterior uveitis in a foal with an umbilical infection and bacteraemia. Uveitis may also be the result of multi-centric neoplasms (Germann, Richter et al. 2008). Most forms of equine ulcerative keratitis are accompanied by some degree of anterior uveitis (Nasisse and Nelms 1992) 2 Therapy past and present As stated earlier, the most common form of therapy for centuries was bloodletting (Braun 1995). Bloodletting was still practised in human ophthalmology in the early 20th century for the management of chronic uveitis. Six to 8 leeches were applied to the temple of the affected side (Fuchs 1945). For a time extirpation of the third eyelid or the cartilage of the nictitans was advocated (Stietenroth 1906; Möller 1910). Hair rope was pulled under the skin below the affected eye and left there for long times to cause artificial suppuration (Zipperlen 1877; Bayer 1892; Bayer 1900). In 1900 Bayer still stated bluntly that therapy for ERU was “powerless”. The situation improved somewhat when solutions of 2-5% cocaine and/or 1-2% atropine were instilled. Adrenalin was also used topically to induce vasoconstriction and to minimize anterior chamber exudation (Möller 1910). This was certainly a less invasive approach than lancing the cornea and draining the exudate (Jakob 1920). Another form of surgical therapy for ERU was the iridectomy practised in the late 19th and early 20th century (Bayer 1900; Möller 1910). A point was made to perform this surgery under general anaesthesia, because it proved too stressful and difficult under topical cocaine anaesthesia alone. The iris was described as being “rotten” in theses cases (Jakob 1920). The surgical results were far from desirable and this form of therapy was later abandoned. Ophthalmology at the time was taught by human ophthalmologists at most European veterinary schools and not surprisingly, new insights from human ophthalmology were applied to veterinary patients.
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